Enlarge image
APPLICATION AND AGREEMENT FOR
PARTIAL TRANSFER OF EXPERIENCE RATING RECORD
Mandatory for Partial Successions
Louisiana Employment Security Law Title 23:1539 & 23:1539.1
Complete this form only if your account acquired a portion of an existing business. If you acquired 100% of another
business, this application does NOT need to be completed.
The partial successor record will receive the taxable payroll for the transferred employees as listed herein. The
successor will also receive the indicated percentage of the predecessor’s reserve, benefit charges, and contributions for
the fiscal year ending immediately prior to the segregation year and for the interim quarters up to the segregation date.
Likewise, these amounts will be deducted from the partial predecessor’s experience rating record for the same period.
1. Successor (Buyer) 2. Predecessor (Seller)
Account No. ________________________________ Account No. ________________________________
Business Name ______________________________ Business Name ______________________________
Address ____________________________________ Address ____________________________________
City, State, Zip ______________________________ City, State, Zip ______________________________
3. Date “segregable and identifiable portion” of organization, trade, or business transferred: M/D/Y ____/____/____.
4. The LA Employment Security Law requires employers involved in a partial succession to advise the Agency of the
percentage of transfer. Both employers must agree on this percentage. The percentage will be used to transfer a
portion of the predecessor’s experience rating record to the successor’s account.
Transferred Portion of Taxable Payroll Total
------------------------------------------------------ = Percentage of Data Transferred _________%
Predecessor’s Taxable Payroll Total
5. We, the predecessor and successor employers, mutually consent to and hereby request the transfer of the
“segregable and identifiable portion” of the predecessor’s experience rating record related to the transferred
portion of the business in accordance with Employment Security Law. Furthermore, we do hereby jointly
certify that the information provided herein and on supplement(s) is true to the best of our knowledge and
belief.
SUCCESSOR PREDECESSOR
_______________________________________ _______________________________________
Signature Signature
_______________________________________ _______________________________________
Title Title
_______________________________________ _______________________________________
D ate Date
_______________________________________ _______________________________________
Telephone No. & Ext. Telephone No. & Ext.
This form must be returned by ___________________. If you fail to return this form by the date indicated, the
Agency/Administrator may perform an audit to determine the percentage of taxable payroll, reserve,
contributions and benefit charges that will be transferred to the partial successor.
PART TRANS APP web (REV 6/09) 1 of 2
